September 2003
Vol.10 No. 4

Editors: Dr. KY Wong
Drs. Karen L Kwong, Sam SP Lau

Role of Paediatricians in Child Protection

Dr. Patricia Ip
Department of Paediatrics & Adolescent Medicine
United Christian Hospital


The role of paediatricians in child protection was once seen as diagnosing abuse and making referrals to social workers. That was a gross understatement of what paediatricians could accomplish. With the opportunity to care for children from neonates to early adulthood, paediatricians are well positioned to see how nature and nurture mould the lives of our young and do our part to foster a positive outcome.

Violence including child abuse and neglect is seen more and more as a public health issue1 with immediate and long-term adverse physical and mental health sequelae. Prevention in public health is traditionally classified into primary, secondary and tertiary. This article will explore what role paediatricians can play in all these levels against child abuse and neglect.

Tertiary Prevention

Tertiary prevention is the recognition of child maltreatment and preventing its recurrence. The maltreatment could be blatant or subtle.

Presentation
A child may be brought in for suspected abuse or has injuries raising the suspicion of abuse; an older child may disclose abuse. Other children present with the less obvious effects of abuse such as failure to thrive, developmental, behavioural or psychosomatic problems. As over-diagnosis can be as devastating as under-diagnosis for the child and the family, we have to understand our limitations and be sensitive, yet not over-sensitive in the recognition of abuse.

Referral
Although the Procedures for handling child abuse cases2 from the Social Welfare Department suggests referral of all suspected cases to the Family and Child Protective Services Unit (FCPSU) and the Police, cases do present in varying degrees of severity. It is impractical and a waste of resources to report all cases. The situation is no different from the management of other paediatric problems. We do not necessarily refer, in the first instance, all children with temper tantrums to clinical psychologists. With suspected child abuse, paediatricians need to exercise their judgement as well. Unlike some countries, which have outlawed corporal punishment,3 FCPSU may not want to see every child with a rattan mark. Children with more serious abuse, parents who are unco-operative or made no progress despite counselling, should be referred. Periodically, families may not see there is a problem or want to resolve the problem within their family and resist intervention. A family or an institution may want to dismiss or transfer out a suspected perpetrator and consider the matter closed. The best interest of each and every child is our concern. For serious abuse, it is no longer a family or an institution's internal affair. Giving the perpetrators an opportunity to move between families or institutions does nothing to protect other children. Although Hong Kong does not have mandatory reporting, professionally, it would be difficult to defend a failure to refer to the appropriate authority for further investigation and management.

Multidisciplinary Approach
Child abuse and neglect is a complex problem that often involves many disciplines. Although there is a need to avoid duplication of effort, paediatricians would not be able to leave all social enquiries to social workers confining ourselves purely to the documentation of injuries. Rarely is the appearance of an injury so clear-cut that we need no further information as to the circumstances in which the injury occurred. Part of the background information could be provided from other sources, but we learn much about the reliability of the information, not from verbal or written communication but from the body language of the informant and the interaction between family members. As paediatricians we are trained to communicate with children and to understand their development. We should be good at bringing out their strength as well as their vulnerability to assist in formulation of the welfare plan.

A multidisciplinary case conference is usually held if a child is admitted with suspected abuse. The purpose of the conference is to share information and decide on the action plan. Periodically, medical staff see their duty only as presentation of the medical report, often confined to the physical findings and then depart. As discussed above, rarely can a medical opinion be based purely on the physical findings. A medical report should include relevant information regarding the past and current history and the social background to support whatever medical opinion is offered. If we want to take an active part in decisions about the welfare of the child and family, we need to know the views of other members at the case conference, and the child and relatives who may be present. The decision then has the ownership of all parties.

Follow-up
It is often not clear whether abused children need to be followed up by paediatricians or only by the caseworker, and mental health care worker, if referred. Children with specific medical problems would of course justify continued medical monitoring. Even if the child does not have a specific medical condition, paediatricians are used to serve as co-ordinators for children who require multi-disciplinary services. It is useful to see the child after the case conference to ensure the child is receiving the services identified and the child and family are on the road to rehabilitation. It also gives the child and family an opportunity to voice their concerns after the acute incident. Unfortunately the default follow-up rate is high especially when children are attended by different medical staff at each visit. Informing the caseworker that the child has defaulted follow-up, at the same time giving an open invitation for re-consultation as required, could avoid different parties relying on each other to take action when contact has in fact been discontinued.

Children who suffered sexual abuse may have symptoms during different stages of their lives e.g. puberty, dating.4 Some children actively request continued follow-up, even if just to say hello. It is as if they want a lifeline to a trusted adult figure. Although the cycle of reabuse is often mentioned, it is also known that abused children do break the cycle. A protective factor is having a support person, whether inside or outside the family who made a difference to their lives.5 If paediatricians could make such a difference, this should be a role we would gladly perform.

Services
Part of the prevention of recurrence of abuse is the rehabilitation of the child and the perpetrator; in fact the whole family may need assistance. Unfortunately therapeutic services are often in high demand and if alternative placement is required, places are in short supply. Paediatricians have a duty to point out that children who have been abused cannot wait. Children who disclose sexual abuse often need immediate services because of the emotional upheaval involved.6 If we do not support the child and the non-offending parent well, the incidence of retraction is much higher. With retraction, it is difficult to take action against the suspected perpetrator and protect the child. Therapy for perpetrators are even more of a problem, partly because such services though exist, are less developed and partly because voluntary participation is unreliable.

In general, children who require alternative placement are best cared for in a family setting although there may be less procedural hurdle getting into an institution. There are now both long term and emergency foster care in Hong Kong but places for the later are limited. Theoretically, any child less than 18 years old could be placed in foster care. In practice, social workers rarely attempt to find such an arrangement for older children and those with adjustment problems are particularly difficult to place. Yet with training and support, and perhaps some monetary incentive, these children do get placed in other countries.

Paediatricians have a role to identify what the best services and arrangements for the optimal development of these children are, and reflect the deficiencies and advocate for redress of such deficiencies.

Secondary Prevention

Secondary prevention focuses at children and families at risk. Recently the Maternal and Child Health Centres of the Department of Health are focusing more on parenting, and vulnerable families would receive additional help. Paediatricians have contact with families for various reasons. If our emphasis is on holistic care and not only treating disease, we can often identify families that may benefit from extra assistance.

Risk factors for abuse could be related to the family, the parents and the child.2 Family characteristics include single-parent families, marital disharmony, domestic violence and social isolation. Parental characteristics include childhood history of abuse, deprivation, alcoholism, substance abuse, gambling, unemployment, mental illness, aggression and generally poor parenting skills. Child characteristics include prematurity, unwanted birth, physical and mental disability, behavioural problems and early separation from parents.

As medical personnel, we often have knowledge of the background of the child and family, which gives some idea of the level of stress a family is facing. Sometimes risk factors are already apparent at birth. Most neonatal units would have a system of referral or provision of assistance and follow-up for these children. Short of formal home visitation programmes7 successful in a number of countries, the service of our community nurses could be enlisted.

Although not to the degree of abuse, not infrequently, we could observe from the child's general condition, state of hygiene, parent-child interaction both physical and verbal, difficulties in parenting. When a child known to have siblings is admitted into hospital, it does no harm to enquire whether other siblings at home are being supervised or left unattended. Paediatricians should be ready to give advice and connect families to resources on parenting and child safety.

Adults can decide to receive help or not for themselves. When children are at risk, we would have to ensure that they do not suffer because of the parental choice. Appropriate arrangement for referral should be made with social service agencies so that at risk children would not fall through the net. A duplicate referral note directed to the agency, followed by a phone call, could reduce the chance of the child not receiving assistance at all.

Primary Prevention

Primary prevention is avoiding putting children at risk of abuse and neglect and to be more positive, promoting a caring and non-violent environment to bring up our children. This could involve preparations for parenthood, support for families, empowerment of children, and policy measures that protect children and families. Traditionally, far more resources are used in remedial work and not enough in primary prevention, yet prevention of abuse in the first place is the kindest of all measures.

As child advocates, paediatricians could take a lead in modifying undesirable child rearing practices. An example would be corporal punishment, which is still widely practised at home. Yet its ill effects are well-documented overseas8 as in local studies.9,10 Doing away with corporal punishment is not equivalent to giving up child discipline. Anticipatory guidance for parents on effective discipline for children at different stages of development is important.

Paediatricians are more and more involved locally in Health Promoting Schools. Raising the awareness of the impact of violence, within families, in the community, and the media, and teaching skills in self-protection and peaceful conflict resolution could pave the way to a more tolerant and safe society.

Child advocacy can be targeted at policy levels. The Convention of the Rights of the Child11 serves a good basis for such advocacy. The recognition of the child as an individual, not an appendage or property of an adult is important. We would then understand more why it is irrational to accept certain behaviour towards a child when the same towards a fellow adult would not be tolerated.

It is important that a child impact study be done on any policy that involves children. Every child has the right to "a standard of living adequate for the child's physical, mental, spiritual, moral and social development" including the benefits of social security.11 It is not a child's choice to receive or not Comprehensive Social Security Assistance. Yet the stigma generated by the society on the recipients and the adequacy of assistance levels to the child are rarely fully studied. Although many children live in caring low-income families, poverty and unemployment in the parents are known risk factors for abuse and neglect.

Children cannot vote. As paediatricians, specialising in the care of children, we should be speaking for them in a strong voice.

Conclusion

Child protection is usually within the realm of community paediatrics, once considered a subspecialty in paediatrics. Now community child health is very much within the ambit of all paediatricians. Hence child protection should not be foreign to any medical personnel working with children and families.

References

  1. World Health Organization. World report on violence and health. Geneva, World Health Organization, 2002.

  2. Social Welfare Department. Procedures for handling child abuse cases. Social Welfare Department, Hong Kong 1998.

  3. End Physical Punishment of Children (EPOCH). Global initiative to end all corporal punishment of children. Available at: http://www.endcorporalpunishment.org/pages/frame.html. Accessed 22nd August, 2003.

  4. Koverola C, Friedrich WN. Psychological effects of child sexual abuse. In: Heger A, Emans SJ, Muram D, editors. Evaluation of the sexually abused child: a medical textbook and photographic atlas. Oxford University Press 2000:21-40.

  5. Jenkins JM, Smith MA. Factors protecting children living in disharmonious homes: maternal reports. J Am Acad Child Adolesc Psychiatry 1990;29:60-9.

  6. Summit RC. The child sexual abuse accommodation syndrome. Child Abuse Negl 1983;7:177-93.

  7. Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 1986;78:65-78.

  8. Straus MA. Beating the devil out of them: Corporal punishment in American Families. Lexington, MA: Lexington Books 1994.

  9. Mok WSJ, Ip PLS Cheung SL, Kam SL. An empirical study of children's perception of corporal punishment and their psychological functioning in a Chinese community. Kwun Tong District Co-ordinating Committee on Family and Child Welfare Services 1999.

  10. Lau JT, Liu JL, Cheung JC, Yu A, Wong CK. Prevalence and correlates of physical abuse in Hong Kong Chinese adolescents: a population-based approach. Child Abuse Negl 1999;23:549-57.

  11. United Nations. Convention on the Rights of the Child. Geneva, United Nations 1989.

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